Use of a natural polysaccharide gel for the preparation of an injectable formulation for treatment of articular degeneration

ABSTRACT

A sterile injectable aqueous formulation in the form of a gel is made up of hyaluronic acid (or one of the salts thereof) with or without other natural polysaccharide(s) and one or more polyols. The formulation is of intra-articular application in the treatment of joint degeneration, in some cases having a rheology similar to that of synovial liquid and always with an elevated resistance to degradation due to a synergistic action between the hyaluronic acid and the polyols.

The invention relates to a sterile, injectable aqueous formulation ingel form that consists of hyaluronic acid (or one of its salts) with orwithout other polysaccharides of natural origin and one or morepolyol(s). This injectable formulation is used in intra-articular spacesin the treatment of articular degeneration.

A joint is a junction that makes it possible to connect two bones and togive them mobility relative to one another.

Synovial joints are the most numerous joints, in particular in thelimbs. In these joints, the bones are joined via a cavity that is filledwith fluid that is both viscous and elastic and that is called synovialfluid.

The sinovial fluid is responsible for the good operation and theprotection of joints. It consists in particular of a polysaccharide,hyaluronic acid, which imparts to the synovial fluid viscoelasticityproperties that make possible, based on imposed constraints, alubrication of the joint or an absorption of impacts.

In the case of articular degeneration such as osteoarthritis of the knee(degeneration due in particular to factors such as obesity, heredity,traumas, . . . ), the synovial fluid degrades (reduction of theconcentration and the molecular weight of the hyaluronic acid), and thisdegradation reduces the capacity of the synovial fluid to lubricate thejoint and to absorb the impacts.

Treatment by viscosupplementation consists in injecting a gel into thejoint so as to replace the deficient synovial fluid. Theviscosupplementation can lessen or stop the pain and contribute torestoring the mobility of the joint.

The viscosupplementation products that are currently on the market aregels that contain hyaluronic acid. These gels can be based on hyaluronicacid of animal or non-animal origin and can be cross-linked (the case ofSynvisc®, Durolane®) or non-cross-linked (the case of Synocrom®,Arthrum®, Lubravisc®, Structovial®).

It is well known to one skilled in the art that the persistence of ahyaluronic-acid-based gel is low in a joint (from several hours toseveral days). According to Laurent, “The Chemistry, Biology and MedicalApplications of Hyaluronan and its Derivatives, Wenner-GrenInternational Series, Volume 72,” the half-life in a rabbit's joint of a1% hyaluronan solution is 12 hours, and that of a 0.5% Hylan B gel is 9days.

This low persistence (kinetics of rapid resorption of gel within thejoint) is explained by a degradation (by depolymerization) of thehyaluronic acid. The primary factors of degradation of the hyaluronicacid in the joint are radical degradation, thermal degradation at 37°C., and mechanical degradation (enzymatic degradation is not asignificant factor of degradation in the joint). Although thetherapeutic effectiveness of the viscosupplement is of longer durationthan its dwell time in the joint, the persistence of a gel based onhyaluronic acid in the joint is a prominent parameter that governs theeffectiveness of the product. Thus, the longer the dwell time of thehyaluronic-acid-based gel in the joint, the more effective theviscosupplementation treatment (reduction of pain, gain in mobility).Consequently, the increase of dwell time (persistence) of a gel withinthe joint is a capital point for increasing the effectiveness of atreatment by viscosupplementation using a hyaluronic-acid-based gel.

It is well known by one skilled in the art that the increase in theconcentration of hyaluronic acid, the use of high molecular weights ofhyaluronic acid and the cross-linking/grafting techniques of thehyaluronic acid make it possible to improve the persistence of ahyaluronic-acid-based gel. However, the optimization of the variousparameters listed above does not seem sufficient to allow thepersistence of a hyaluronic-acid-based gel to increase significantly inintra-articular spaces (the half-life, within the joint, of currentviscosupplementation gels that are on the market is only several days atmost).

In a development that was absolutely unexpected and surprising, it wasdemonstrated that:

-   -   The presence of a polyol in a sterile aqueous formulation that        is based on hyaluronic acid makes it possible to increase        significantly the resistance to the degradation of this gel    -   A strong affinity of the hyaluronic acid and the polyol within        the sterile gel involves a slow kinetics for release of the        polyol outside of the gel: this affinity between the hyaluronic        acid and the polyol involves an effective long-term protection        of the gel by the polyol by a synergetic action    -   For a particular composition of an aqueous formulation of        hyaluronic acid and a polyol, the sterilization gives this gel        viscoelastic properties that are absolutely astonishing in that        they virtually reproduce the viscoelastic properties of the        uncontaminated synovial fluid—these particular rheological        properties of the gel are maintained longer during the period        due to the protection against the degradation that is induced by        the “hyaluronic acid/polyol” synergy.

This invention therefore consists of a sterile, injectable aqueousformulation in gel form that consists of hyaluronic acid (or one of itssalts) with or without other polysaccharides of natural origin and ofone or more polyol(s). This formulation, used in the treatment ofarticular degeneration, in some cases (see Examples 1 and 3) presents arheology that is close to that of synovial fluid and always an increasedresistance to degradation.

Example 4 shows the best resistance of a hyaluronic-acid-based gel and apolyol when the latter is subjected to a radical, thermal and mechanicaldegradation test. This best resistance of the gel to degradation allowsa longer persistence of the gel that is injected into intra-articularspaces.

Example 5 shows the best resistance of a hyaluronic-acid-based gel and apolyol to thermal degradation. This best resistance of the gel tothermal degradation makes possible a longer persistence of the gel thatis injected into intra-articular spaces and a better stability of theformulation during storage of the product before use (important pointfor the expiration period of the product).

Example 8 demonstrates the strong affinity between the hyaluronic acidand a polyol. Injected into the joint, the strong affinity between thehyaluronic acid and the polyol allows a better long-term resistance ofthe gel to degradation by a synergetic action. Actually, in the case ofan injection of a polyol solution into the joint, the natural washingwill quickly eliminate the molecule (=polyol) from the joint. In thecase of a hyaluronic-acid-based gel with polyol, the strong affinitybetween the hyaluronic acid and the polyol will prevent the quickrelease of polyol outside of the gel (and therefore its quickelimination outside of the joint) and will thus make possible effectivelong-term protection of the gel by polyol against degradation.

Examples 1 and 3 show a rheology of a hyaluronic-acid-based gel and apolyol that is close to that of the synovial fluid.

The publication of MAZZUCCO, D. et al., “Rheology of Joint Fluid inTotal Knee Arthroplasty Patients”; Journal of Orthopedic Research,1157-1163, 2002, indicates that the frequency of crossover between theelastic modulus G′ and the viscous modulus G″ is equal to 0.41±0.12 Hzfor an uncontaminated (non-osteoarthritic) synovial fluid of the knee.The value of this crossover frequency is confirmed by the publication ofFam et al., “Rheological Properties of Synovial Fluids,” Biorheology,44, 59-74, 2007. In this publication, a figure has the crossoverfrequency between the moduli G′ and G″ of between 0 and 10 Hz for asynovial fluid that belongs to a young or old individual or else for anosteoarthritic synovial fluid.

-   -   Below 0.41 Hz: G″>G′, the synovial fluid has a predominantly        viscous function, meaning that the joint is strongly lubricated        when the patient is at rest.    -   Above 0.41 Hz: G′>G″, the synovial fluid has a predominantly        elastic function, meaning that impacts are strongly absorbed        when the patient runs or jumps.

According to one aspect of this invention, the gel that consists of anaqueous solution of hyaluronic acid (or one of its salts) with orwithout other polysaccharides of natural origin and one or morepolyol(s) has, after sterilization, a crossover frequency f_(c) betweenthe elastic modulus G′ and the viscous modulus G″ that is close to 0.41Hz. Thus, the gel has viscoelastic properties that are close to that ofthe synovial fluid.

As a result, according to one aspect of this invention:

-   -   Below f_(c): G″>G′, the gel has a predominantly viscous        function, meaning that the joint is effectively lubricated when        at rest.    -   Above f_(c): G′>G″, the gel has a predominantly elastic        function, meaning that impacts are effectively absorbed when the        patient runs or jumps (protection of the joint).

According to one aspect of this invention, the crossover frequency isbetween 0 and 10 Hz, preferably 0.41±0.41 Hz. This kind of rheology istherefore appropriate to the mechanical constraints of joints and inparticular of the knee, the hip or small joints. Consequently, it has agreat advantage in the treatment of osteoarthritis byviscosupplementation of the knee or other joints.

FIGS. 1-5 show viscous and elastic moduli of gels according to oneaspect of this invention while

FIGS. 6-9 show those of commercial gels.

FIGS. 10 and 11 illustrate the kinetics of radical, thermal andmechanical degradation of gels and the hyaluronic acid/polyol affinity.

The invention therefore relates to the use of a sterile, injectableaqueous formulation in gel form that consists of hyaluronic acid (or oneof its salts) at 1-100 mg/ml with or without other polysaccharide(s) ofnatural origin and one or more polyol(s) at 0.0001-100 mg/ml. Thisinjectable formulation in used in intra-articular spaces in thetreatment of articular degeneration.

The hyaluronic acid is preferably obtained by biofermentation but it canalso be of animal origin. Its molecular weight is 0.1 to 10×10⁶ Da andpreferably 2 to 3×10⁶ Da.

The concentration of hyaluronic acid is between 1 and 100 mg/ml andpreferably between 10 and 25 mg/ml.

The polysaccharide(s) of natural origin that can be used in combinationwith the hyaluronic acid is selected from among, for example,chondroitin sulfate, keratan, keratan sulfate, heparin, heparin sulfate,cellulose and its derivatives, chitosan, xanthans, alginates, and all oftheir respective salts.

Hyaluronic acid, just like the polysaccharide(s) of natural origin, canbe cross-linked or non-cross-linked, grafted or non-grafted according tothe cross-linking/grafting techniques described in the prior art.

The polyol(s) is/are selected from among, for example, glycerol,propylene glycol, sorbitol, mannitol, erythritol, xylitol, lactitol,maltitol or else cyclic oses such as glucose.

The polyol concentration is between 0.0001 and 100 mg/ml and preferablybetween 15 and 45 mg/ml.

The aqueous solution that is used is preferably a buffered solution. Thecomposition of this buffer solution is selected so as to have thedesired physico-chemical (pH, osmolarity) and rheological properties.

Preferably, the buffer solution that is selected is a phosphate buffersolution.

According to this invention, the formulation is sterilized by thetechniques that are well known to one skilled in the art and preferablywith the autoclave.

The formulation according to this invention is used by injection intothe joint, and the dose that is injected can be between 0.1 and 20 mlbased on the nature of the treated joint.

By way of illustration, two viscoelastic gel formulations that can beprepared according to this invention are provided below:

-   -   Viscoelastic gel based on hyaluronic acid and glycerol    -   Sterile solution that consists of 20 mg/ml of hyaluronic acid        (MM=2.5×10⁶ D) and 20 mg/ml of glycerol in the phosphate buffer.    -   Viscoelastic gel based on hyaluronic acid and sorbitol    -   Sterile solution that consists of 20 mg/ml of hyaluronic acid        (MM=2.5×10⁶ D) and 40 mg/ml of sorbitol in the phosphate buffer.

EXAMPLES

Examples are proposed so as to illustrate the invention but are in noway limiting of said invention. The formulations that are prepared inthe following examples are gels based on sodium hyaluronate (NaHA) thatare non-cross-linked or cross-linked with polyol.

The preparation of non-cross-linked or cross-linked gels is carried outaccording to the techniques that are well known by one skilled in theart. The sodium hyaluronate that is used to produce these gels has amolecular weight that is equal to 2.5×10⁶ Da. In the case of thecross-linked gels, the cross-linking agent that is used is BDDE, and thedefinition of the cross-linking level that is used is: weight(BDDE)/weight (dry NaHA).

The incorporation of polyol in the gel is carried out by adding thenecessary amount of polyol in the non-cross-linked or cross-linked geland by mixing it with the spatula for 10 minutes (per 100 g of finalgel).

The prepared gels are filled into glass syringes and then sterilizedwith moist heat (T=121° C.).

The rheometer that is used to carry out the rheological measurements isan AR1000 (TA Instruments) with a flat geometry of 40 mm, a gap of 1000microns, and an analytical temperature of 37° C.

The metering of the polyols is carried out by an HPLC Ultimate 3000(Dionex) and an ion exchange column.

Example 1 Preparation of Sterile Injectable Formulations According tothe Invention

Formulation A: Gel based on non-cross-linked NaHA with glycerol

-   -   15 mg of NaHA at 2.5×10⁶ D    -   20 mg of glycerol    -   Enough for 1 ml of phosphate buffer        Formulation B: Gel based on non-cross-linked NaHA with glycerol    -   15 mg of NaHA at 2.5×10⁶ D    -   20 mg of glycerol    -   Enough for 1 ml of phosphate buffer        Formulation C: Gel based on non-cross-linked NaHA with propylene        glycol    -   20 mg of NaHA at 2.5×10⁶ D    -   20 mg of propylene glycol    -   Enough for 1 ml of phosphate buffer        Formulation D: Gel based on non-cross-linked NaHA with mannitol    -   20 mg of NaHA at 2.5×10⁶ D    -   15 mg of mannitol    -   Enough for 1 ml of phosphate buffer        Formulation E: Gel based on non-cross-linked NaHA with sorbitol    -   20 mg of NaHA at 2.5×10⁶ D    -   40 mg of sorbitol    -   Enough for 1 ml of phosphate buffer        Formulation F: Gel based on cross-linked NaHA with sorbitol    -   18 mg of NaHA at 2.5×10⁶ D, cross-linking level=6%    -   50 mg of sorbitol    -   Enough for 1 ml of phosphate buffer

Example 2 Physicochemical Properties of the Formulations of Example 1

-   -   pH (at ambient temperature)

Formulation pH A 7.0 B 7.2 C 7.1 D 7.0 E 7.1 F 7.1

-   -   Osmolarity

Formulation Osmolarity (mOsm/kg) A 335 B 322 C 324 D 315 E 326 F 338*indicates Examples within the present invention, and **indicatesComparative Examples.

The formulations A, B, C, D, E and F are isotonic and have a neutral pH.

Example 3 Rheological Properties of the Formulations of Example 1

The viscoelastic properties of the formulations A, B, C, D and E arecharacterized by measuring the evolution of the viscous modulus (G″) andthe elastic modulus (G′) based on frequency (see FIGS. 1 to 5).

For these 5 formulations, it is noted that the crossover frequency ofthe modulus G′ and the modulus G″ is close to that of the uncontaminatedsynovial fluid.

The table below provides crossover frequency values f_(c) for eachformulation and for uncontaminated synovial fluid.

Formulation Crossover Frequency f_(c) (Hz) A 0.50 B 0.32 C 0.32 D 0.32 E0.33 Uncontaminated Synovial Fluid 0.41 ± 0.12 (Publication by Mazzucco,D. et al.)

As described in this invention:

-   -   Below f_(c): G″>G′, the gel has a predominantly viscous        function, meaning that the joint is effectively lubricated when        at rest.    -   Above f_(c): G′>G″, the gel has a predominantly elastic        function, meaning that impacts are effectively absorbed when the        patient runs or jumps

Example 4 Resistance to Degradation of the Formulations of Example 1

To show that the presence of a polyol in an NaHA-based gel makes itpossible to reduce the degradation of the gel by a radical, thermal andmechanical action, the resistance to the degradation of NaHA-based gelswith polyol (formulations of Example 1) and the resistance to thedegradation of NaHA-based gels without polyol (=reference gels) werecompared.

For the formulations B, C, D and E of Example 1, the NaHA-basedreference gel without polyol is a non-cross-linked NaHA-based gel with20 mg/ml of NaHA (MM=2.5×10⁶ D, in the phosphate buffer)—formulation G.

For the formulation F of Example 1, the NaHA-based reference gel withoutpolyol is a cross-linked NaHA-based gel with 18 mg/ml of NaHA(MM=2.5×10⁶ D before cross-linking, in the phosphate buffer) that has across-linking level of 6%—formulation H.

The degradation test is carried out by adding an oxidizing agent to thegel to be tested, by homogenizing the mixture with the spatula for 1minute, by being brought to the temperature of 37° C., and by imposing adeformation of 0.3%. The value of the parameter tan δ=G″/G′ at 0.7 Hz(characteristic parameter of the viscoelastic properties of the gel) ismeasured over time.

It is noted that this parameter increases over time, synonymous with agradual breakdown of the gel. The values that are measured at t=0 andt=15 minutes for the formulations B, C, D, E, F, G and H are provided inthe table below.

Tanδ Tanδ ΔTanδ Formulation (t = 0 min) (t = 15 min) (%) B 1.10 3.34+204% C 1.08 3.13 +205% D 1.19 4.63 +289% E 1.08 2.57 +138% F 0.74 0.80 +8% G 1.41 6.56 +365% H 0.74 0.93  +26%

As described in this invention, each formulation B, C, D and E has aresistance to degradation that is significantly higher than that of thegel without polyol (formulations G). Likewise, the formulation F has aresistance to degradation that is significantly higher than that of thecorresponding gel without polyol (formulations H).

Consequently, the polyols protect the gel effectively againstdegradation.

Example 5 Study of Accelerated Aging of a Formulation with and withoutPolyol

Two formulations are subjected to accelerated furnace aging at 40° C.:

-   -   Formulation B of Example 1: Solution based on hyaluronic acid        and glycerol    -   Formulation G without addition of alcohol (described in Example        4)        -   20 mg of hyaluronic acid with 2.5×10⁶ D        -   Enough for 1 ml of phosphate buffer

A measurement of zero viscosity (zero-shear viscosity) and adetermination of the crossover frequency f_(c) between the elasticmodulus G′ and the viscous modulus G″ is carried out at 3 times (t=0, 7days, 26 days)

The results that are obtained are provided in the table below:

Number of Days Zero Viscosity of Aging at Variation Variation of f_(c)40° C. Formulation Zero Viscosity Relative to to (%) f_(c) (Hz) Relativeto to (%) 0 Day B 252 / 0.32 / G 192 / 0.39 / 7 Days B *ND / 0.32  0% G*ND / 0.39  0% 26 Days B 210 −17% 0.37 +16% G 143 −26% 0.50 +28% *ND =Not Determined

It is noted that during the accelerated aging, the loss of zeroviscosity and the offsetting of the crossover frequency f_(c) are lessin the case of the formulation B (formulation according to thisinvention) than in the case of the formulation without polyol(formulation G).

Example 6 Comparison of the Rheology of 4 CommercialViscosupplementation Products and a Formulation that is ObtainedAccording to this Invention

The tested products are as follows:

Molecular Concentration Weight of of Hyaluronic Hyaluronic SterilizationProduct Trade Name Manufacturer Acid (mg/ml) Acid (Da) Method P1Synocrom ® CROMA 10 2.2-2.7 · 10⁶    Moist Heat PHARMA P2 Structovial ®CROMA 10 2.2-2.7 · 10⁶    Moist Heat PHARMA P3 Fermathron ® HYALTECH 101 · 10⁶ Filtration P4 Lubravisc ® BOHUS 10 4 · 10⁶ Moist Heat BIOTECHFormulation A of Not Applicable Not Applicable 15 2.5 · 10⁶   Moist HeatExample 1 (+20 mg/ml of Glycerol)

For the 5 gels tested, FIGS. 6-9 provide the viscous modulus (G″) andthe elastic modulus (G′) based on the frequency.

It is noted that only the gel according to Example 1 has a crossoverfrequency (0.50 Hz) that is close to that of the uncontaminated synovialfluid (0.41 Hz).

The table below combines the values of the crossover frequencies f_(c)for the products P1 to P4 and for the formulation A of Example 1.

Product f_(c) (Hz) Formulation A 0.50 of Example 1 P1 5.8 P2 5.0 P3 6.3P4 0.09

It is known that according to the publication of Mazzucco, D. et al.(cited above), the crossover frequency of the uncontaminated synovialfluid (0.41 Hz) is below the frequencies that are observed in the kneeduring walking (0.7 Hz) and running (3 Hz).

For the products P1 to P3, the crossover frequency is higher than 3 Hz,and, consequently, the products do not have strong elasticity allowingthe absorption of impacts when the knee is moving.

The product P4 has a very low crossover frequency; the elastic modulusis higher than the viscous modulus over the entire frequency range of0.1-10 Hz. Consequently, the elasticity is high when the knee is moving,but the lubrication of the joint is not very effective when the patientis at rest.

Example 7 Comparison of the Resistance to Degradation of 3 CommercialViscosupplementation Products and a Formulation that is ObtainedAccording to this Invention

The tested products are as follows:

Concentration of Hyaluronic Product Trade Name Manufacturer Acid (mg/ml)T1 Arthrum ® LCA Pharmaceutical 20 T2 Ostenil ® TRB Chemedica 10 T3Synocrom ® CROMA PHARMA 10 Formulation E Not Applicable Not Applicable20 of Example 1 (+40 mg/ml of Sorbitol)

The degradation test is carried out according to the method that isdescribed in Example 4.

The value of the parameter G′ at 0.7 Hz is tracked over time.

The thus obtained rheology curves are provided in FIG. 10.

It is noted that the gel according to this invention becomessignificantly degraded less quickly than the 3 commercial productstested.

Example 8 Demonstration of the Strong Hyaluronic Acid/Polyol Affinity

So as to demonstrate the strong affinity between the hyaluronic acid andthe polyol and therefore the long-term protection of the gel by thepolyol, a follow-up study of the release of a polyol by dialysis hasbeen carried out.

5 g of the formulation E (gel based on 20 mg/ml of non-cross-linked NaHAand 40 mg/ml of sorbitol—Example 1) was introduced into a dialysismembrane (No. 1) (Spectra/Pore®, MWCO: 12-14,000).

5 g of a phosphate buffer solution that contains 40 mg/ml of sorbitolwas introduced into a 2^(nd) dialysis membrane (No. 2) (Spectra/Pore®,MWCO: 12-14,000)—same dimension as the membrane No. 1.

These membranes were placed in respective bottles containing 50 g ofpurified water (=dialysis bath) while being stirred magnetically.Measurements of sorbitol concentration by HPLC were carried out in thedialysis baths at different times so as to track the kinetics forrelease of sorbitol outside of the membrane with gel or a buffersolution.

The tracking curves of the sorbitol concentration over time are providedin FIG. 11.

The kinetics for release of sorbitol into a gel is significantly slowerthan in a buffer solution.

This study promotes the synergy between the hyaluronic acid and thepolyol that is present in the gel: the strong hyaluronic acid/polyolaffinity makes it possible for the polyol to be present within the gelover a long period, and the protection capacity of the polyol withregard to the gel makes it possible to have a strong long-termresistance of the gel against degradation.

1-18. (canceled)
 19. Sterile, injectable aqueous formulation, used inintra-articular spaces, in the form of gel containing hyaluronic acid orone of its salts at 1-100 mg/ml and optionally one or more otherpolysaccharides of natural origin, and one or more polyols at 0.0001-100mg/ml, obtained by preparation of an aqueous composition that containshyaluronic acid or one of its salts, optionally one or more otherpolysaccharides of natural origin, and one or more polyols, and then bysterilization of this composition, wherein the gel that is obtained hasa crossover frequency of the elastic modulus G′ and the viscous modulusG″ of between 0 and 10 Hz, preferably 0.41±0.41 Hz, whereby G′ isgreater than G″ at high frequency.
 20. Formulation according to claim19, wherein the hyaluronic acid is non-cross-linked or essentiallynon-cross-linked.
 21. Formulation according to claim 19, wherein thehyaluronic acid is cross-linked.
 22. Formulation according to claim 19,wherein the concentration of hyaluronic acid or of one of its salts is10 to 25 mg/ml and the concentration of polyol(s) is 15 to 45 mg/ml. 23.Formulation according to claim 19, wherein the hyaluronic acid (or oneof the salts) by itself or mixed has a molecular weight of 0.1 to 10×10⁶Da, and the polyol, by itself or in a mixture, is glycerol, propyleneglycol, sorbitol, mannitol or glucose.
 24. Formulation according toclaim 19, wherein the hyaluronic acid has a molecular weight of 2 to3×10⁶ Da.
 25. Formulation according to claim 19, wherein the hyaluronicacid concentration is 20 mg/ml and that of glycerol is 20 mg/ml. 26.Formulation according to claim 19, wherein the hyaluronic acidconcentration is 20 mg/ml and that of sorbitol is 40 mg/ml. 27.Formulation according to claim 19, where the sterilization is carriedout in the autoclave.
 28. Process for preparation of a sterile,injectable aqueous formulation in gel form according to claim 19,comprising the stages that consist in preparing an aqueous compositionthat contains hyaluronic acid or one of its salts, optionally one orseveral other polysaccharides of natural origin, and one or morepolyols, and in sterilizing the composition that is thus obtained. 29.Process for preparation according to claim 28, wherein the sterilizationis carried out in the autoclave.
 30. Method of treating a patient witharticular degeneration, which comprises injecting an effective amount ofa formulation according to claim 19 in an intra-articular space.
 31. Themethod according to claim 30, wherein the formulation is injected at arate of 0.1 to 20 ml.
 32. Formulation according to claim 20, wherein thehyaluronic acid is non-cross-linked or essentially non-cross-linked. 33.Formulation according to claim 20, wherein the hyaluronic acid iscross-linked.
 34. Formulation according to claim 21, wherein theconcentration of hyaluronic acid or of one of its salts is 10 to 25mg/ml and the concentration of polyol(s) is 15 to 45 mg/ml. 35.Formulation according to claim 32, wherein the concentration ofhyaluronic acid or of one of its salts is 10 to 25 mg/ml and theconcentration of polyol(s) is 15 to 45 mg/ml.